Provider Demographics
NPI:1992034631
Name:STANLEY, OWEN (MS, ATC, CSCS, EMT)
Entity Type:Individual
Prefix:MR
First Name:OWEN
Middle Name:
Last Name:STANLEY
Suffix:
Gender:M
Credentials:MS, ATC, CSCS, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MISSOURI ATHLETICS 239 CHAMPIONS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65211-0001
Mailing Address - Country:US
Mailing Address - Phone:573-239-8177
Mailing Address - Fax:
Practice Address - Street 1:239 CHAMPIONS DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65211-0001
Practice Address - Country:US
Practice Address - Phone:979-862-6005
Practice Address - Fax:979-847-8514
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-09
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT66212255A2300X
SD03282255A2300X
MO20070088632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
110202002OtherATHLETIC TRAINING